The registered nurse told federal inspectors on November 12 that she was "unsure of what setting Resident 18's air mattress should be set on" and referred the question to the Director of Nursing nearby.
The DON explained that air mattresses should be set according to the resident's weight. When inspectors followed up with the nurse one minute later, she confirmed the bed was indeed set to 170-230 pounds — nearly 100 pounds heavier than the resident's actual weight of 136 pounds.
The resident had been lying in this incorrect position since returning from lunch around 1:00 PM, the nurse confirmed. Facility policy required repositioning every two hours.
Inspectors observed the resident continuing to complain of pain at 3:52 PM. The registered nurse asked if they would like Tylenol for their discomfort.
She did not offer to reposition the resident.
Only after being prompted by the federal surveyor did the nurse offer repositioning assistance, which the resident accepted. The DON helped move the resident.
Nine minutes later, inspectors interviewed the resident again. Repositioning had helped "some" with their rear pain, they said.
The inspection revealed a second incident involving medication errors that had persisted for six days. Resident 3 had an active order to clean wounds on their right ear twice daily with wound cleanser and apply bacitracin-zinc with a cotton-tipped applicator. The order had been in effect since November 6.
On November 12 at 1:02 PM, inspectors watched the DON prepare wound care supplies at the nurse's station. She checked orders in a binder, gathered supplies in a plastic container, and went to the resident's room.
After treating moisture-associated skin damage on the resident's thigh and buttocks, two aides helped move the resident from bed to wheelchair. The DON performed hand hygiene, opened sterile gauze, put on new gloves, and squirted wound cleanser onto the gauze.
She cleaned the resident's right upper ear with the gauze, disposed of materials, and performed hand hygiene again. After putting on new gloves, she applied Hydrogel to a Q-tip and rubbed it into the crease of the resident's upper right ear.
The DON then removed her gown and gloves, packed supplies back into the container, and returned to the nurse's station.
When inspectors interviewed her at 1:58 PM, the DON confirmed she had used Hydrogel for the ear treatment. She stated she "did not realize Resident 3's order had been changed from Hydrogel to bacitracin-zinc six days prior."
The Registered Nurse Consultant confirmed one minute later that the treatment order had indeed been changed from Hydrogel to bacitracin-zinc in the electronic medical records six days earlier.
For six consecutive days, Resident 3 received the wrong medication on their ear wound while the correct treatment order sat in the electronic system.
The violations occurred during a complaint investigation at Skyview Care and Rehab at Bridgeport. Federal inspectors determined the deficiencies caused actual harm to some residents.
The air mattress incident highlighted fundamental gaps in staff knowledge about basic medical equipment. The registered nurse responsible for the resident's care couldn't operate a pressure-relief mattress properly — equipment designed specifically to prevent the kind of pain and tissue damage the resident experienced.
The medication error revealed a breakdown in communication between electronic records and actual care delivery. While the facility had updated Resident 3's treatment orders in their computer system, the information never reached the DON performing the daily wound care.
Both cases demonstrated failures in the most basic nursing responsibilities: knowing how to use medical equipment and following current medication orders. The resident left on the wrong mattress setting experienced unnecessary pain for hours. The resident receiving incorrect ear medication went nearly a week without proper treatment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Skyview Care and Rehab At Bridgeport from 2025-11-17 including all violations, facility responses, and corrective action plans.
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